Sylan Shores Health and Wellness
3950 Underwood Rd, La Porte, TX 77571 · Government - Hospital district · 124 certified beds · (832) 861-6910 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,281 in federal fines (most recent 2025-07-25)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (70%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.0% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 3.0% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.6% | 2.4% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.2% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.1% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.8% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.9% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 3.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 14.2% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.6% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.4% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 61.0% | 88.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.6% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.9% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.01 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.12 | 2.06 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 73 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 40.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 52 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.1%CMS range 36.1–57.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.4–15.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 40.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 34.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 51.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.6%CMS range 4.2–14.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.26 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 124 beds and averages 105.6 residents a day — about 85% occupied, or roughly 18 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.00 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.21 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.58 hrs/resident/day on weekends vs 3.18 on weekdays — 19% thinner on weekends. RN hours go from 0.23 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 70% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 11 most serious are shown; the remaining 5 are one tap away and print in full.
- Immediate jeopardy · J2025-07-23 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 111 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure Resident #1 was free from sexual abuse when Resident #1's was kissed by CNA A and her hand came in to contact with CNA A's penis on 7/13/25. The noncompliance was identified as Past Non-Compliance immediate jeopardy (IJ). The IJ began on 7/13/25 and ended on 7/17/25. The facility corrected the noncompliance before the survey began. This failure placed facility residents at risk of experiencing abuse and neglect. Findings include: Record review of Resident #1's admission Record dated 07/14/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with major depressive disorder (mental health disorder characterized by persistently depressed mood). Record review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-24 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 (Resident #3 and Resident #6) of 6 residents reviewed for quality of care.The facility failed to ensure Resident #3's fall on 10/09/2025 and Resident #6's fall on 11/07/2025 were in their respective care plan s.This failure placed residents at risk of not receiving appropriate care and interventions to meet their needs. Resident #3Record review of Resident #3's face sheet dated 11/24/2025, she was a [AGE] year-old female originally admitted to the facility on [DATE] and last re-admitted on [DATE] with medical diagnoses including Alzheimer's disease (a progressive brain disease that cause memory loss), hypertension (high blood pressure), repeated falls, Major Depressive Disorder (a mental illness characterized by prolonged periods of sadness and feelings of worthlessness, dysphagia (difficulty swallowing) and generalized anxiety disorder…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-23 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident receives an accurate assessment reflecting the resident's status for 3 of 23 residents reviewed for assessment accuracy (Residents #7, #58, #63, #99).Bed rails used for positioning and turning were coded on the MDS as physical restraints for Residents #7, #58, #63, #99. These failures placed residents at risk of having inaccurate assessments and receiving improper care and services. Findings include: Resident #7Record review of Resident #7's face sheet revealed admission date 1/31/23 with diagnoses including Alzheimer's disease (loss of memory and mental functions), heart disease, major depressive disorder (depression or loss of interest affecting daily life), hypertension (high blood pressure), Myocardial infarction (decreased blood flow to the heart), cerebral infarction (stroke). Record review of Resident #7's Quarterly MDS dated [DATE] revealed short -and long -term memory loss, moderately impaired cognitive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-23 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 of 1 medication fridges and 1 of 4 medication carts reviewed for storage. The facility failed to ensure that medication fridges and medication carts were free of expired medications. The failure could place residents at risk of receiving expired medications. Findings included:Observation and interview with ADON A on 7/21/25 at 3:25 p.m. of the facility's medication room revealed expired medications in the medication refrigerator. The expired medications were as follows:*one dose of Ceftriaxone 2 mg/100 ml with expiration date of 7/13/25, *two doses of Meropenem 500 mg/100 ml with expiration date of 6/19/25, and *three doses of Meropenem 500 mg/100 ml with expiration date of 6/14/25.ADON A said regarding the Meropenem the resident labeled to that medication had been in the hospital a long time. ADON A said they usually checked the medication refrigerator once a week for expired medications. ADON A said those types…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-04 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure each resident was treated with respect and dignity, and care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 5 residents (Resident #10) reviewed for resident's rights, in that: -Resident #10 whose bedsheet was pulled over her face during incontinence care, while she was crying, was not treated with dignity or respect in her own room. This failure placed residents who are totally dependent on staff for incontinence care, at risk for having feelings of poor self-esteem, decreased self-worth, and loss of dignity. Findings: Record review of Resident #10's Face sheet revealed a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, abnormalities of gait and mobility (abnormal walking pattern with many possible causes like an injury, sore or inner ear issue or nerve damage), muscle weakness (when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-04 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation was made for 1 (Resident #15) of 5 residents reviewed for reporting of alleged violations, in that: The facility failed to report to the state agency, an incident of neglect regarding Resident #15, after she had an unwitnessed fall in her room with a possible injury to her hip that occurred on 6/21/24. The unwitnessed fall later revealed through x-ray, Resident #15 had a left femur fracture, and it was not reported to the state until 06/25/2024 which was four days after the incident occurred. This failure could place facility residents at risk of injury of unknown origin, abuse, and neglect. Findings : Record review of Resident #15's Face sheet revealed a [AGE] year-old female who admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-12 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 18 residents (Resident #66) reviewed for their right to voice grievances to the facility. The facility failed to report and document Resident #66's complaint about her hearing aids that stopped working after a shower. This failure could place residents at risk for harm by not having their grievances addressed. The findings included: Record review of Resident #66's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included, but were not limited to, Essential hypertension (high blood pressure), type 2 diabetes mellitus without complications (a problem in the way the body regulates and uses sugar as a fuel), chronic kidney disease, cardiac pacemaker, heart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-12 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 3 (Resident #6, #61 and #66) of 24 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #6 was coded in the MDS for a fall. The facility failed to ensure Resident #61 was coded correctly in the MDS for a fall. The facility failed to accurately assess Resident #66 for her cognitive patterns (mental capacity) on her admission MDS assessment. These failures could place residents at risk of not having all medical needs assessed and met. Findings Included: Resident #6 Record review of Resident #6's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included, but were not limited to, Multiple Sclerosis, muscular dystrophies (diseases that cause progressive weakness and loss of muscle mass) urinary tract infection, intellectual disability, anxiety abnormalities of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-12 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. There were 2 errors out of 25 opportunities which resulted in an 8% error rate involving 1 of 4 residents (Resident #89) and 1 of 3 employees (MA A) observed during medication administration reviewed for medication error, in that: -MA A gave Resident #89 an incorrect dose of her Famotidine and antacid and antihistamine medication. -MA A gave Resident #89 an incorrect dose of her Tylenol a pain relieving and fever reducing medication. These failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medication and or adverse outcomes. The findings were: Resident #89 Record review of Resident #89's admission Record revealed she was an [AGE] year old female who admitted to the facility on [DATE] with the following diagnoses: allergic rhinitis (an allergic response causing itching, watery eyes, sneezing, and runny nose), gastro-esophageal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-13 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 4 of 13 residents (Resident #6, Resident #72, Resident #78, and Resident #105) reviewed for pharmacy services. MA A failed to administer Morphine, a pain medication, to Resident #6 within the scheduled administration window. The facility failed to ensure the Medication Room did not contain expired IV medications for Residents #78 and #105. The facility failed to ensure the 400 hall nursing cart did not contain expired Insulin and supplements for Resident #72. These failures could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. Findings Included Resident #6 Record review of Resident #6's Face Sheet dated 04/12/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: motor and sensory neuropathy (nerve pain), opioid dependence, legal blindness and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-13 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 22 percent based on 8 errors out of 36 opportunities, which involved 4 of 8 residents (Resident #24, Resident #39, Resident #60 and Resident #69) reviewed for medication errors. - MA B failed to administer medication as ordered to Resident #60 by administering Artificial Tears containing Glycerin, Hypromellose and Polyethylene Glycol instead of Artificial Tears containing Carboxymethylcellulose. - MA B failed to administered medication as ordered to Resident #24 by administering Lidocaine 4% Patch, a patch used for pain, instead of Lidocaine 5% and applied the patch to the right knee instead of right rib cage. - MA A failed to administer Resident #69's blood pressure medications Hydrochlorothiazide, Losartan and Acebutolol even though the resident's BP fell within acceptable parameters. - MA A failed to administer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · E2023-04-13 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts (400 Hall Nursing Cart and 200 Hall Nursing Cart) reviewed for medication storage. - The facility failed to ensure the 400 Hall Nursing Cart did not contain insulin pens with no open date - The facility failed to ensure the 200 Hall Nursing Cart did not contain insulin pens with no pharmacy labels. This failure could place residents at risk of adverse medication reactions. Findings Included: 400 Hall Nursing Cart Resident #18 Record review of Resident #18's Face Sheet dated [DATE] revealed, a [AGE] year-old male admitted on [DATE] with diagnoses which included: type 2 diabetes and depression. Record review of Resident #18's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-13 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY intake ID # 418120\TX00452588 Based on interview and record review, the facility failed to coordinate the PASRR assessment for specialized services for 1 of 4 resident reviewed for PASRR coordination and assessment. (Resident #75) The facility failed to submit a NFSS request for nursing facility specialized services in the LTC Online Portal for Resident #75's OT, PT, and ST specialized services by a specific deadline. This failure could place residents with intellectual and developmental disabilities at risk for not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: Record review of Resident #75's electronic face sheet reflected he was a 55- year old male, admitted to the facility on [DATE]. His diagnoses included seizures, intellectual disability, Autistic disorder (condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-13 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan meet professional standards of quality for 1 of 14 residents (Resident #61) reviewed for professional standards: The facility failed to ensure Resident #61 had an active physician order for her Wander guard device. A Wanderguard is a safety device placed on an individual who is high risk for unsafe wandering that alerts the responsible party when that individual attempts to exit a building/designated area. This failure to meet professional standards of entering and following physician orders could place residents at risk for inadequate care or inadequate monitoring. Findings included: Record review of Resident #61's face sheet revealed that resident was a [AGE] year-old woman admitted to facility on 9/28/2022 with diagnoses of unspecified dementia (progressive loss of mental ability; thinking, decision making, memory), heart failure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Intake ID #418036\TX00453051 Based on observation, interview, and record review, the facility failed to provide supervision to each resident to prevent accidents for 1 of 6 residents (Resident #61) reviewed as part of sample. The facility failed to ensure that all facility exit doors were secured to prevent unsupervised wandering of residents out of the facility. This failure could place wandering residents at risk for being lost or harmed. Findings included: Record review of Resident #61's face sheet revealed that resident was a [AGE] year-old woman admitted to facility on 9/28/2022 with diagnoses of unspecified dementia (progressive loss of mental ability; thinking, decision making, memory), heart failure (decreased ability of heart to pump blood), sedative, hypnotic, anxiolytic dependence , cerebral infarction (stroke), and cognitive communication deficit (decreased ability to express thoughts/communicate effectively). Record review of Resident #61's assessments showed a positive Elopement Assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-13 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurately documented for 1 of 15 residents (Resident #6) whose records were reviewed. - MA A failed to document administration of Morphine ER 15 mg, an opioid used to treat pain, until 1 hour and 20 minutes after administration. These failures could place residents at risk for inadequate errors leading to medication errors and adverse reactions. Findings Included: Record review of Resident #6's Face Sheet dated 04/12/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: motor and sensory neuropathy (nerve pain), opioid dependence, legal blindness and absence of right and left leg below the knee. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, supervision on most ADLs, always…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,281 in federal fines across 1 penalty.
- $8,281 — penalty dated 2025-07-25
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to ML HEALTHCARE — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.3 | -1.3 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 1 of 5 | 1.2 | -0.2 vs chain |
| Quality measures | 3 of 5 | 4.5 | -1.5 vs chain |
The other 5 homes this chain runs (chain average 2.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FRIO HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2024 |
| RUFF, MICHAEL | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| ML - LA PORTE, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| LANGSDALE, TROY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| MILLER, LAURA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| MOHAMMED, SHAFRAZ | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| MARTEL HEALTHCARE MANAGEMENT LLC | Organization | ADP OF THE SNF | — | since 01/01/2024 |
| MDP HEALTHCARE LLC | Organization | ADP OF THE SNF | — | since 01/01/2024 |
| ROBINSON REALTY GROUP LTD | Organization | ADP OF THE SNF | — | since 01/01/2024 |
| SMITHERS MANAGEMENT TRUST | Organization | ADP OF THE SNF | — | since 01/01/2024 |
| CARDENAS, LAURA | Individual | ADP OF THE SNF | — | since 01/01/2024 |
CMS files one row per role, so the 15 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676490. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.